Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 15, Issue 9, pp 1094–1100 | Cite as

Patellofemoral contact pressure following high tibial osteotomy: a cadaveric study

  • Karl Stoffel
  • Craig Willers
  • Omar Korshid
  • Markus Kuster


Patella infera is a known complication of high tibial osteotomy (HTO) that can cause anterior knee pain due to excessive stresses associated with abnormal patellofemoral (PF) joint biomechanics. However, the translation of these abnormal biomechanics to native cartilage pressure has not been explored. The present study was designed to compare the PF contact pressures of three different HTOs in a human cadaveric model of valgus tibiofemoral correction. Nine fresh cadaveric knees underwent (1) medial opening wedge (OWHTO) with a proximal tuberosity osteotomy (PTO), (2) OWHTO with a distal tuberosity osteotomy (DTO), and (3) a lateral closing wedge (CWHTO). The specimens were mounted in a custom knee simulation rig, with muscle forces being simulated using a pulley system and weights. The PF contact pressure was recorded using an electronic pressure sensor at 15°, 30°, 60°, 90°, and 120° of knee flexion, with results of the intact knees obtained as relative control. Compared to the intact knee, the DTO OWHTO and CWHTO did not significantly (P > 0.05) influence PF pressure at any flexion angle. On the other hand, PTO OWHTO lead to a significant elevation in PF cartilage pressure at 30° (P < 0.05), 60° (P < 0.005), and 90° (P < 0.0005) knee flexion. We conclude from these results that DTO OWHTO maintains normal joint biomechanics and has no significant effect on PF cartilage pressure. In patients who complain of pre-existing anterior knee pain, DTO OWHTO or CWHTO should be considered.


Cartilage pressure Patellofemoral Osteotomy Distal Tibial tuberosity 


  1. 1.
    Adili A, Bhandari M, Giffin R, Whately C, Kwok DC (2002) Valgus high tibial osteotomy comparison between an Ilizarov and a Coventry wedge technique for the treatment of medial compartment osteoarthritis of the knee. Knee Surg Sports Traumatol Arthrosc 10:169–176PubMedCrossRefGoogle Scholar
  2. 2.
    Agneskirchner JD, Hurschler C, Stukenborg-Colsman C, Imhoff AB, Lobenhoffer P (2004) Effect of high tibial flexion osteotomy on cartilage pressure and joint kinematics: a biomechanical study in human cadaveric knees Winner of the AGA-DonJoy award 2004. Arch Orthop Trauma Surg 124:575–84PubMedCrossRefGoogle Scholar
  3. 3.
    Ahmed (1988) The effect of quadriceps tension characteristics on the patellar tracking pattern. In: Presented at 34th annual meeting ORS, AtlantaGoogle Scholar
  4. 4.
    Amendola A, Rorabeck CH, Bourne RB, Apyan PM (1989) Total knee arthroplasty following high tibial osteotomy for osteoarthritis. J Arthroplasty 4(Suppl):S11–S17PubMedCrossRefGoogle Scholar
  5. 5.
    Andriacchi TP, Mundermann A, Smith RL, Alexander EJ, Dyrby CO, Koo S (2004) A framework for the in vivo pathomechanics of osteoarthritis at the knee. Ann Biomed Eng 32:447–457PubMedCrossRefGoogle Scholar
  6. 6.
    Berman AT, Bosacco SJ, Kirshner S, Avolio A Jr (1991) Factors influencing long-term results in high tibial osteotomy. Clin Orthop Relat Res 192–208Google Scholar
  7. 7.
    Brouwer RW, Bierma-Zeinstra SM, van Koeveringe AJ, Verhaar JA (2005) Patellar height and the inclination of the tibial plateau after high tibial osteotomy. The open versus the closed-wedge technique. J Bone Joint Surg Br 87:1227–1232PubMedCrossRefGoogle Scholar
  8. 8.
    Bullough PG (1992) The pathology of osteoarthritis. WB Saunders, Philadelphia, pp 39–69Google Scholar
  9. 9.
    Cameron HU, Park YS (1996) Total knee replacement following high tibial osteotomy and unicompartmental knee. Orthopedics 19:807–808PubMedGoogle Scholar
  10. 10.
    Carter DR, Beaupre GS, Wong M, Smith RL, Andriacchi TP, Schurman DJ (2004) The mechanobiology of articular cartilage development and degeneration. Clin Orthop Relat Res S69–S77Google Scholar
  11. 11.
    Coventry MB (1979) Upper tibial osteotomy for gonarthrosis. The evolution of the operation in the last 18 years and long term results. Orthop Clin North Am 10:191–210PubMedGoogle Scholar
  12. 12.
    Coventry MB, Bowman PW (1982) Long-term results of upper tibial osteotomy for degenerative arthritis of the knee. Acta Orthop Belg 48:139–156PubMedGoogle Scholar
  13. 13.
    Coventry MB, Ilstrup DM, Wallrichs SL (1993) Proximal tibial osteotomy. A critical long-term study of eighty-seven cases. J Bone Joint Surg Am 75:196–201PubMedGoogle Scholar
  14. 14.
    Dejour H, Neyret P, Boileau P, Donell ST (1994) Anterior cruciate reconstruction combined with valgus tibial osteotomy. Clin Orthop Relat Res 220–228Google Scholar
  15. 15.
    Elias JJ, Wilson DR, Adamson R, Cosgarea AJ (2004) Evaluation of a computational model used to predict the patellofemoral contact pressure distribution. J Biomech 37:295–302PubMedCrossRefGoogle Scholar
  16. 16.
    Engel GM, Lippert FG 3rd (1981) Valgus tibial osteotomy: avoiding the pitfalls. Clin Orthop Relat Res 137–143Google Scholar
  17. 17.
    Flahiff CM, Kraus VB, Huebner JL, Setton LA (2004) Cartilage mechanics in the guinea pig model of osteoarthritis studied with an osmotic loading method. Osteoarthritis Cartilage 12:383–388PubMedCrossRefGoogle Scholar
  18. 18.
    Gaasbeek RD, Sonneveld H, van Heerwaarden RJ, Jacobs WC, Wymenga AB (2004) Distal tuberosity osteotomy in open wedge high tibial osteotomy can prevent patella infera: a new technique. Knee 11:457–461PubMedCrossRefGoogle Scholar
  19. 19.
    Gill TJ, DeFrate LE, Wang C, Carey CT, Zayontz S et al (2003) The biomechanical effect of posterior cruciate ligament reconstruction on knee joint function. Kinematic response to simulated muscle loads. Am J Sports Med 31:530–536PubMedGoogle Scholar
  20. 20.
    Goutallier D, Hernigou P, Medevielle D, Debeyre J (1986) Outcome at more than 10 years of 93 tibial osteotomies for internal arthritis in genu varum (or the predominant influence of the frontal angular correction). Rev Chir Orthop Reparatrice Appar Mot 72:101–113PubMedGoogle Scholar
  21. 21.
    Goutallier D, Julieron A, Hernigou P (1992) Cement wedge replacing iliac graft in tibial wedge osteotomy. Rev Chir Orthop Reparatrice Appar Mot 78:138–144PubMedGoogle Scholar
  22. 22.
    Hasler EM, Herzog W (1998) Quantification of in vivo patellofemoral contact forces before and after ACL transection. J Biomech 31:37–44PubMedCrossRefGoogle Scholar
  23. 23.
    Hernigou P, Goutallier D (1987) Outcome of the femoropatellar joint in osteoarthritic genu varum after tibial wedge osteotomy for angulation 10 to 13 year regression. Rev Chir Orthop Reparatrice Appar Mot 73:43–48PubMedGoogle Scholar
  24. 24.
    Hernigou P, Ma W (2001) Open wedge tibial osteotomy with acrylic bone cement as bone substitute. Knee 8:103–110PubMedCrossRefGoogle Scholar
  25. 25.
    Hernigou P, Medevielle D, Debeyre J, Goutallier D (1987) Proximal tibial osteotomy for osteoarthritis with varus deformity. A ten to thirteen-year follow-up study. J Bone Joint Surg Am 69:332–354PubMedGoogle Scholar
  26. 26.
    Hoell S, Suttmoeller J, Stoll V, Fuchs S, Gosheger G (2005) The high tibial osteotomy, open versus closed wedge, a comparison of methods in 108 patients. Arch Orthop Trauma Surg 125:638–643PubMedCrossRefGoogle Scholar
  27. 27.
    Hofmann AA, Kane KR (1994) Total knee arthroplasty after high tibial osteotomy. Orthopedics 17:887–890PubMedGoogle Scholar
  28. 28.
    Huberti HH, Hayes WC (1984) Patellofemoral contact pressures The influence of q-angle and tendofemoral contact. J Bone Joint Surg Am 66:715–724PubMedGoogle Scholar
  29. 29.
    Hughston JC, Deese M (1988) Medial subluxation of the patella as a complication of lateral retinacular release. Am J Sports Med 16:383–388PubMedCrossRefGoogle Scholar
  30. 30.
    Insall JN (1981) Patella pain syndromes and chondromalacia patellae. Instr Course Lect 30:342–356PubMedGoogle Scholar
  31. 31.
    Insall JN, Joseph DM, Msika C (1984) High tibial osteotomy for varus gonarthrosis. A long-term follow-up study. J Bone Joint Surg Am 66:1040–1048PubMedGoogle Scholar
  32. 32.
    Islam N, Haqqi TM, Jepsen KJ, Kraay M, Welter JF et al (2002) Hydrostatic pressure induces apoptosis in human chondrocytes from osteoarthritic cartilage through up-regulation of tumor necrosis factor-alpha, inducible nitric oxide synthase, p53, c-myc, and bax-alpha, and suppression of bcl-2. J Cell Biochem 87:266–278PubMedCrossRefGoogle Scholar
  33. 33.
    Jackson JP, Waugh W (1974) The technique and complications of upper tibial osteotomy. A review of 226 operations. J Bone Joint Surg Br 56:236–245PubMedGoogle Scholar
  34. 34.
    Jackson M, Sarangi PP, Newman JH (1994) Revision total knee arthroplasty. Comparison of outcome following primary proximal tibial osteotomy or unicompartmental arthroplasty. J Arthroplasty 9:539–542PubMedCrossRefGoogle Scholar
  35. 35.
    Jakob RP, Jacobi M (2004) Closing wedge osteotomy of the tibial head in treatment of single compartment arthrosis. Orthopade 33:143–152PubMedCrossRefGoogle Scholar
  36. 36.
    Kaper BP, Bourne RB, Rorabeck CH, Macdonald SJ (2001) Patellar infera after high tibial osteotomy. J Arthroplasty 16:168–173PubMedCrossRefGoogle Scholar
  37. 37.
    Katz MM, Hungerford DS, Krackow KA, Lennox DW (1987) Results of total knee arthroplasty after failed proximal tibial osteotomy for osteoarthritis. J Bone Joint Surg Am 69:225–233PubMedGoogle Scholar
  38. 38.
    Li G, DeFrate LE, Zayontz S, Park SE, Gill TJ (2004) The effect of tibiofemoral joint kinematics on patellofemoral contact pressures under simulated muscle loads. J Orthop Res 22:801–806PubMedCrossRefGoogle Scholar
  39. 39.
    Li G, Park SE, DeFrate LE, Schutzer ME, Ji L et al (2005) The cartilage thickness distribution in the tibiofemoral joint and its correlation with cartilage-to-cartilage contact. Clin Biomech (Bristol, Avon) 20:736–744CrossRefGoogle Scholar
  40. 40.
    Lobenhoffer P, Agneskirchner J, Zoch W (2004) Open valgus alignment osteotomy of the proximal tibia with fixation by medial plate fixator. Orthopade 33:153–160PubMedCrossRefGoogle Scholar
  41. 41.
    Lobenhoffer P, Agneskirchner JD (2003) Improvements in surgical technique of valgus high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 11:132–138PubMedGoogle Scholar
  42. 42.
    Lootvoet L, Massinon A, Rossillon R, Himmer O, Lambert K, Ghosez JP (1993) Upper tibial osteotomy for gonarthrosis in genu varum. Apropos of a series of 193 cases reviewed 6 to 10 years later. Rev Chir Orthop Reparatrice Appar Mot 79:375–384PubMedGoogle Scholar
  43. 43.
    Marti RK, Verhagen RA, Kerkhoffs GM, Moojen TM (2001) Proximal tibial varus osteotomy. Indications, technique, and five to twenty-one-year results. J Bone Joint Surg Am 83-A:164–170PubMedGoogle Scholar
  44. 44.
    Matthews LS, Goldstein SA, Malvitz TA, Katz BP, Kaufer H (1988) Proximal tibial osteotomy. Factors that influence the duration of satisfactory function. Clin Orthop Relat Res 193–200Google Scholar
  45. 45.
    Mont MA, Alexander N, Krackow KA, Hungerford DS (1994) Total knee arthroplasty after failed high tibial osteotomy. Orthop Clin North Am 25:515–525PubMedGoogle Scholar
  46. 46.
    Mont MA, Antonaides S, Krackow KA, Hungerford DS (1994) Total knee arthroplasty after failed high tibial osteotomy. A comparison with a matched group. Clin Orthop Relat Res 125–30Google Scholar
  47. 47.
    Morrell KC, Hodge WA, Krebs DE, Mann RW (2005) Corroboration of in vivo cartilage pressures with implications for synovial joint tribology and osteoarthritis causation. Proc Natl Acad Sci USA 102:14819–14824PubMedCrossRefGoogle Scholar
  48. 48.
    Naudie D, Bourne RB, Rorabeck CH, Bourne TJ (1999) The Install Award. Survivorship of the high tibial valgus osteotomy A 10- to -22-year followup study. Clin Orthop Relat Res 18–27Google Scholar
  49. 49.
    Noda T, Yasuda S, Nagano K, Takahara Y, Namba Y, Inoue H (2000) Clinico-radiological study of total knee arthroplasty after high tibial osteotomy. J Orthop Sci 5:5–36CrossRefGoogle Scholar
  50. 50.
    Noyes FR, Mayfield W, Barber-Westin SD, Albright JC, Heckmann TP (2006) Opening wedge high tibial osteotomy: an operative technique and rehabilitation program to decrease complications and promote early union and function. Am J Sports Med 34(8):1262–1273PubMedCrossRefGoogle Scholar
  51. 51.
    Powers CM, Lilley JC, Lee TQ (1998) The effects of axial and multi-plane loading of the extensor mechanism on the patellofemoral joint. Clin Biomech (Bristol, Avon) 13:616–624CrossRefGoogle Scholar
  52. 52.
    Rudan JF, Simurda MA (1990) High tibial osteotomy. A prospective clinical and roentgenographic review. Clin Orthop Relat Res 251–256Google Scholar
  53. 53.
    Scuderi GR, Windsor RE, Insall JN (1989) Observations on patellar height after proximal tibial osteotomy. J Bone Joint Surg Am 71:245–248PubMedGoogle Scholar
  54. 54.
    Shea JD (1973) Osteoarthrosis of the knee: diagnosis and complications of treatment by high tibial osteotomy. South Med J 66:1030–1034PubMedGoogle Scholar
  55. 55.
    Stoffel K, Stachowiak G, Kuster M (2004) Open wedge high tibial osteotomy: biomechanical investigation of the modified Arthrex Osteotomy Plate (Puddu Plate) and the TomoFix Plate. Clin Biomech (Bristol, Avon) 19:944–950CrossRefGoogle Scholar
  56. 56.
    Tigani D, Ferrari D, Trentani P, Barbanti-Brodano G, Trentani F (2001) Patellar height after high tibial osteotomy. Int Orthop 24:331–334PubMedCrossRefGoogle Scholar
  57. 57.
    Toksvig-Larsen S, Magyar G, Onsten I, Ryd L, Lindstrand A (1998) Fixation of the tibial component of total knee arthroplasty after high tibial osteotomy: a matched radiostereometric study. J Bone Joint Surg Br 80:295–297PubMedCrossRefGoogle Scholar
  58. 58.
    Trindade MC, Shida J, Ikenoue T, Lee MS, Lin EY et al (2004) Intermittent hydrostatic pressure inhibits matrix metalloproteinase and pro-inflammatory mediator release from human osteoarthritic chondrocytes in vitro. Osteoarthr Cartil 12:729–735PubMedCrossRefGoogle Scholar
  59. 59.
    Vanwanseele B, Eckstein F, Knecht H, Stussi E, Spaepen A (2002) Knee cartilage of spinal cord-injured patients displays progressive thinning in the absence of normal joint loading and movement. Arthr Rheum 46:2073–2078CrossRefGoogle Scholar
  60. 60.
    Warden SJ, Morris HG, Crossley KM, Brukner PD, Bennell KL (2005) Delayed- and non-union following opening wedge high tibial osteotomy: surgeons’ results from 182 completed cases. Knee Surg Sports Traumatol Arthrosc 13:34–37PubMedCrossRefGoogle Scholar
  61. 61.
    Westacott CI, Urban JP, Goldring MB, Elson CJ (2002) The effects of pressure on chondrocyte tumour necrosis factor receptor expression. Biorheology 39:125–132PubMedGoogle Scholar
  62. 62.
    Westrich GH, Peters LE, Haas SB, Buly RL, Windsor RE (1998) Patella height after high tibial osteotomy with internal fixation and early motion. Clin Orthop Relat Res 169–174Google Scholar
  63. 63.
    Windsor RE, Insall JN, Vince KG (1988) Technical considerations of total knee arthroplasty after proximal tibial osteotomy. J Bone Joint Surg Am 70:547–555PubMedGoogle Scholar
  64. 64.
    Wright JM, Heavrin B, Begg M, Sakyrd G, Sterett W (2001) Observations on patellar height following opening wedge proximal tibial osteotomy. Am J Knee Surg 14:163–173PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2007

Authors and Affiliations

  • Karl Stoffel
    • 1
  • Craig Willers
    • 2
  • Omar Korshid
    • 1
  • Markus Kuster
    • 1
  1. 1.Fremantle Orthopaedic DepartmentUniversity of Western Australia, Fremantle HospitalFremantleAustralia
  2. 2.Department of Orthopaedic Surgery, School of Surgery and PathologyUniversity of Western Australia, QE2 Medical CentreNedlandsAustralia

Personalised recommendations